Incorporating Brazilian and Latin American perspectives in the ICD-11 classification of mental and behavioral disorders

EDITORIAL

Department of Mental Health and Substance Abuse, World Health Organization

The constitutional responsibilities of the World Health Organization (WHO) include: (1) establishing and revising international nomenclatures of diseases, causes of death, and public health practices; and (2) standardizing diagnostic procedures.¹ The WHO is currently revising the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), and the ICD-11 is scheduled for approval by the World Health Assembly in 2014. The ICD is the international standard for the assessment and monitoring of mortality, morbidity, and other health parameters. WHO member countries are required by international treaties to collect and report health statistics to the WHO using the ICD as a framework.

The WHO Department of Mental Health and Substance Abuse is leading the development of the ICD-11 classification of mental and behavioral disorders. The Department's highest priority is to help WHO member countries, particularly those with fewer resources, to reduce the disease burden and disability associated with mental disorders. Neuropsychiatric disorders account for 13% of global disease burden, more than any other category of non-communicable disease.² A minority of people with severe mental disorders - fewer than 25% in developing countries - receive any treatment at all,³ and only a small percentage of such treatment is provided by psychiatrists.

A key aim of the ICD-11 classification of mental and behavioral disorders is to enable more widespread and efficient identification and prioritization of people with mental disorders who need treatment. People with mental disorders are more likely to receive the services they need if health workers in the settings where they are most likely to come into contact with the health system have a diagnostic system that is reliable, valid, clinically useful, and feasible. Substantial concerns have been expressed regarding the clinical utility of current classification systems for mental disorders,⁴ which apply to both the ICD-10 and to the American Psychiatric Association's DSM-IV. The most important contributor to the poor clinical utility of current psychiatric diagnostic systems is their extraordinary complexity, which is unnecessary for many clinical applications and does not support the efficient use of limited treatment resources at the clinical or country level.

This public health perspective underlies WHO's requirements for the ICD revision. First, to impact global public health, the development of the ICD-11 must also be global, giving users in all parts of the world a meaningful opportunity to shape the final product. Securing strong participation from developing countries is a challenge and a requirement. A second, related requirement is that the revision must be multilingual. Cultural and regional specificities are embedded in language, and if there is no attention to translation and linguistic equivalence until the end of the process, reduced clinical utility for non-English versions is a predictable result. The WHO has already conducted an analysis of Latin American classification systems,⁵ but we must also engage more directly with regional constituents for the revision.

Third, the revision effort must be multidisciplinary. As noted, the vast majority of people with mental disorders worldwide will never see a psychiatrist. In order to serve as a tool to reduce disease burden, the ICD-11 classification of mental and behavioral disorders will need to be usable by a much broader range of health care personnel. The WHO views all health professionals who use the mental disorders classification as a constituency for its revision.

Fourth, the WHO recognizes the users of mental health services and their family members as a direct stakeholder group in the ICD revision process. The user community in mental health has been increasingly aligned with the disability rights movement, adopting the motto of 'Nothing about us without us!', rejecting what they see as medical paternalism and demanding to be consulted about the decisions that affect their lives. The ICD revision process must encompass substantive opportunities for participation of user groups that can contribute constructively to the revision process.

This was the context in which the WHO Department of Mental Health and Substance Abuse asked the Department of Psychiatry of the Universidade Federal de São Paulo to organize a forum that would enable the WHO to engage with and begin to learn from the diversity of Brazilian and Latin American perspectives relevant to the development of the ICD-11. The meeting on 'Classification of Mental and Behavioral Disorders in Latin America' was held on 17-18 May 2010, in São Paulo, and included approximately 50 experts in mental and behavioral disorders diagnosis and classification from Brazil, Argentina, Mexico, and Peru.

Based on the important and substantive nature of the discussions at the meeting, the Revista Brasileira de Psiquiatria issued an open call for articles on 'The Latin American Contribution to the Revision of the ICD-10', specifically intended to provide relevant information to the WHO and its working groups. The top proposals were selected by the editorial board and the resulting articles are collected in this supplement. The authors' perspectives are their own, and do not represent the official policies of the WHO, but they highlight a number of critical issues that the WHO Department of Mental Health and Substance Abuse must consider in attempting to develop a classification with global public health utility. We look forward to continued collaboration with our Brazilian and Latin American colleagues in order to incorporate scientific and practical knowledge from the region and to ensure that the new ICD-11 classification system adequately reflects the region's perspectives and clinical realities. This engagement will support WHO's broader effort to reduce the disease burden of mental disorders throughout the world.

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References

• 1. World Health Organization - WHO. Basic documents. 46th ed. Geneva, Switzerland: World Health Organization; 2007.
• 2. World Health Organization - WHO. The global burden of disease: 2004 update. Geneva, Switzerland: World Health Organization; 2008.
• 3. Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, Angermeyer MC, Bernert S, de Girolamo G, Morosini P, Polidori G, Kikkawa T, Kawakami N, Ono Y, Takeshima T, Uda H, Karam EG, Fayyad JA, Karam AN, Mneimneh ZN, Medina-Mora ME, Borges G, Lara C, de Graaf R, Ormel J, Gureje O, Shen Y, Huang Y, Zhang M, Alonso J, Haro JM, Vilagut G, Bromet EJ, Gluzman S, Webb C, Kessler RC, Merikangas KR, Anthony JC, Von Korff MR, Wang PS, Brugha TS, Aguilar-Gaxiola S, Lee S, Heeringa S, Pennell BE, Zaslavsky AM, Ustun TB, Chatterji S; World Health Organization World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health surveys. JAMA. 2004;291(21):2581-90.
• 4. Reed GM. Toward ICD-11: improving the clinical utility of WHO's international classification of mental disorders. Prof Psychol Res Pract. 2010;41(6):457-64.
• 5. Rivas Rodríguez M, Reed GM, First MB, Ayuso-Mateos JL. Aportaciones de dos clasificaciones psiquiátricas latinoamericanas para el desarrollo de la CIE-11. Rev Panam Salud Pública. 2011;29(1):130-7.

Incorporating Brazilian and Latin American perspectives in the ICD-11 classification of mental and behavioral disorders

Geoffrey M. Reed

Publication Dates

• Publication in this collection
  18 Aug 2011
• Date of issue
  May 2011